The future of dental practice; time is of the essence
A groundbreaking Scottish report has put pressure on UK governments to act decisively on support for the profession and to tackle COVID-19's impact on oral health
The Scottish Dental Clinical Effectiveness Programme (SDCEP) published its keenly anticipated ‘rapid review’ report on aerosol generating procedures (AGPs)and COVID-19 last month.1
In response to the report, the British Dental Association (BDA) urged all four nations of the UK to consider its recommendations and to “move forward in a clear and coordinated way”. The BDA said dentists and patients needed clarity on how essential treatments should now be provided. However, it also noted that patients should be clear that any resulting changes will not mean a return to “normal” dental care.
The review was initiated and conducted independently by SDCEP.
But – as one member who was invited to sit on the group described the urgency among officials as lockdown continued – the Office of the Chief Dental Officers (CDOs) wanted to “get to grips with issues frustrating the profession”. Held in high regard for its work on antimicrobial resistance, antibiotic prophylaxis, dental amalgam and periodontal care, SDCEP began work on the review at the end of June with the support of the UK CDOs.
It convened a multidisciplinary working group with representatives from all four UK nations supported by a methodology team, including members of Cochrane Oral Health. The aim was to identify and appraise all available evidence related to several pre-determined key questions about AGPs in dentistry. Using a considered judgment of this evidence and other relevant factors a number of agreed positions that could inform policy and clinical guidance were reached.
“For almost three months I have worked alongside remarkable academics, virologists, physicists, public health officials, and other wet fingered dentists,” said Mick Armstrong, a member of the group, and former chair of the British Dental Association.
“The process engulfed our lives as hours of virtual meetings piled on top of intensive review work It almost felt like being a student again waking up to spend two hours on aerosol physics or epidemiology on a Thursday morning. But that was what was necessary to compile this report.”
It is not, the authors emphasised on its publication, new government guidance, but rather it is a review which aims to inform policy makers.
The group assessed past and current scientific evidence for aerosols and mitigation factors from around the world. It looked at the available evidence relating to the generation and mitigation of aerosols in dental practice and the associated risk of COVID-19 transmission, and reached a number of agreed positions (a 75 per cent majority of members’ opinion was required) including:
- High volume suction and rubber dam use is recommended to reduce the risk of COVID-19 transmission
- The use of fallow time is recommended, the length of which varies between 10 and 60 minutes and depends on the ventilation rate, high volume suction and rubber dam use
- Pre-procedural mouth rinses and anti-microbial coolants are not recommended for use to reduce risk of virus transmission.
The recommendations will be reviewed as more evidence emerges; the authors cautioned that the evidence base is “currently quite weak”.
However, the BDA commented that the report was a “thorough piece of work and valuable resource for dentists in these challenging times”. The association has outlined some likely implications for practices; training may be required and improving ventilation is likely to be costly and require specialist technical support.
On the issue of ventilation, Mick Armstrong added: “This is a public health measure and it is a reasonable ask of the government to help get dentistry back on its feet. This act would show the kind of commitment to our profession that we have needed since the outbreak first took shape.”
For the profession as a whole, the concern remains the safety of patients, the dental team and the financial viability of dental practices. If these recommendations evolve into requirements, said the BDA, then Governments will need to “step up and offer direct financial support.”
In a statement it added: “We will continue to campaign on your behalf and update you on any changes. Until new guidance is issued, we urge you to follow existing Government guidance on AGPs and COVID-19.”
Jeremy Bagg, who is Professor of Clinical Microbiology at Glasgow University and Head of the Glasgow Dental School, chaired the working group. He told Scottish Dental magazine: “Fears over the potential transmission of SARS-CoV-2 via the airborne route during dental aerosol generating procedures have resulted in the requirement for fallow times between patients, which dramatically impact on surgery capacity and significantly reduce access to dental care for patient
“The lack of reliable evidence in this area complicates assessment of the overall balance of risks and harms. Since late June the multi-professional Working Group that was established by SDCEP to undertake the Rapid Review has worked tirelessly, guided by the evidence appraisal led by the SDCEP core team and Cochrane Oral Health, to develop the set of considered judgements that were published on 25 September.
“As chair of the working group, I would like to acknowledge publicly the commitment of all concerned. The thoughtful, collaborative and respectful ways in which all the members engaged was central to completion of this very challenging project within the timeframe achieved. Furthermore, the huge volume of work undertaken by the SDCEP central team, under considerable time pressure, was remarkable. If the output of the Rapid Review are reflected in the official guidance that will follow, then all of these efforts will have been very worthwhile.”
Jan Clarkson, the Director of SDCEP, Associate Postgraduate Dental Dean at NHS Education for Scotland and Professor of Clinical Effectiveness at Dundee University, added: “The SDCEP rapid review was a truly incredible experience. Rarely do you have an opportunity to work on an urgent issue for the profession and public, with a committed group of researcher experts, dental professionals and patients. Over 13 weeks the working group met as many times to agree considered judgements based on the available evidence.
“The urgency of the SDCEP review resulted in an exciting and unique situation with expert researchers offering to assist the core team and openly share pre-published findings. The rapid review has been an intense and enjoyable experience with a clear and agreed purpose, to inform guidance development. We have agreement from all involved to enable us to be agile, committing to make this a living review, updating it as new evidence emerges.
“As director of SDCEP, I thank Jeremy for chairing the working group so brilliantly and for his unstinting support for the team in this ambitious undertaking. I could not have been prouder of the team or more impressed by the wide range of individuals, who engaged freely and openly to make evidence-informed considered judgements in this time of national emergency.”
The report was welcomed by The Faculty of General Dental Practice UK and College of General Dentistry. It noted that among the key positions – and in contrast to those adopted to-date in official protocols – the report divided dental procedures into three categories of aerosol generation potential according to the instruments used, with fallow periods recommended only for the highest risk procedures, and suggested the determination of fallow time using a multifactorial approach, with a `benchmark’ of 15-30 minutes.
The FGDP-CGDent’s own guidance, published in June and updated earlier this month2,3, also set out a more nuanced approach to considering the generation of aerosols in dental practice.
Ian Mills, Dean of FGDP(UK), and member of the SDCEP’s review group, said: “SDCEP’s review of dental AGPs has been extremely thorough and followed a rigorous and methodical approach. Its publication is potentially a very significant moment in the recovery of dental practices in the midst of the coronavirus pandemic and I commend the SDCEP team for the hard work and dedication they have shown in producing this report.
“We welcome in particular the more refined stratification of the transmission risk inherent in types of dental procedure; the allowance for fallow time to be calculated from the cessation of the procedure; and the sophisticated approach to calculating fallow time, which considers both procedural and environmental mitigation factors such as high-volume suction, the use of rubber dam and provision of adequate air ventilation
“These approaches align exceptionally well with our own guidance and we feel it is important that current standard operating procedures are reviewed in light of SDCEP’s recommendations. Adoption of these measures will enable the increased delivery of patient care to tackle the backlog of unmet need and avoid further deterioration in dental access and oral health inequality.
“A reduction in fallow time will also support the viability of practices, while the maintenance of universal precautions will continue to keep both patients and members of the dental team safe. We have updated our guidance and have worked with partners to develop an online ‘fallow time calculation tool’ to support its implementation.”
Mick Armstrong was clear about the need for clear evidence concerning AGPs.4 “[They] have become the single biggest point of contention in dentistry since the outbreak of the coronavirus pandemic. Initially relegated to the confines of urgent dental care, under strict protocols of enhanced PPE [personal protective equipment], the return to practice has meant AGPs are further restricted by fallow time rules.This hour-long period in which treatment rooms had to be empty has had severe repercussions for practice throughput and further punished a sector already on its knees.
“The profession has cried out for evidence, detail and guidance and this review hopes to provide some answers,” he said. “I truly believe that this is the report the profession has been looking for. It reflects the fact that the science is not comprehensive and outlines how we can best ensure public and staff safety. We now need and eagerly await Government policy and hope any new instructions reflect the tireless work by SDCEP.”
Armstrong reiterated the report’s fundamental purpose: “[It] outlines our methodology and agreed positions and is a series of recommendations on the generation and mitigation of aerosols in dental practice and the associated risk of COVID-19 transmission. As professionals, we are all familiar with AGPs but for the first time we now delineate between different categories. There are high-risk procedures that require fallow time and lower risk procedures that can be dealt with using standard control precautions.
“The group has agreed that a pragmatic fallow time of between 10 and 60 minutes is recommended to reduce the risk of coronavirus transmission through the use of a series of mitigation techniques. The use of high-volume suction, already estimated to be used by 94 per cent of practices, could reduce fallow time to 20 minutes if applied effectively. Likewise, the use of rubber dams for restorative dental procedures that produce aerosol is also recommended.
“But the key to reducing fallow time is ensuring a high ventilation rate. It is essential that dental care providers investigate the air change rate to ensure they comply with guidance that treatment rooms should have at least 10 air changes per hour – an open window is probably not enough. Mechanical ventilation ensuring at least10 changes per hour should bring fallow time down to 10 minutes, plus 10 minutes cleaning time, in line with our recommendations.
“If fallow time can be reduced to 10 minutes then dentist capacity could increase significantly – possibly up to between 60 and 70 per cent of pre-COVID 19 capacity. That would vastly reduce the current threat to dentist viability and really begin to tackle the worrying impact that lockdown has inevitably had on the population’s oral health.”